Health History Form - Reflux, Stomach Pain, Ulcers

Patient Name

Date of Birth

Pre-Admission Questionnaire

Primary Care Physician

Endoscopist

Procedure

Reason for Procedure

May we leave medical information on an answering machine or voicemail? Yes No

May we discuss procedure results with anyone other than you? Yes No
If yes, who?

Do you have an advance directive (Health Care Proxy)? Yes No
If yes, who?

If No, would you like any additional information? Yes No

Name and telephone number of person who will be driving you home after the procedure:

Name

Telephone Number

Please answer the following about your personal history:

Heart disease/Murmur/Valve disease Yes No

Explanation if yes

High Blood Preassure Yes No

Explanation if yes

Breathing/Lung problems Yes No

Explanation if yes

Seizures/Stroke/Epilepsy Yes No

Explanation if yes

Liver or Kidney Disease Yes No

Explanation if yes

Diabetes Yes No

Explanation if yes

Arthritis/Limitations of movement Yes No

Explanation if yes

Bleeding problems/Blood thinners Yes No

Explanation if yes

Problems with anesthesia or sedation Yes No

Explanation if yes

Recreational drug use? Yes No

Explanation if yes

Are you pregnant or nursing? Yes No

Explanation if yes

Pregnancy test taken? Yes No

Explanation if yes

Pregnancy test waiver signed (if applicable)? Yes No

Explanation if yes

Do you drink alcohol? How much?

Do you smoke? How much? How long?

Any other medical problems not listed above? List surgical operations

Are you allergic or sensitive to medications? Yes No

If yes, list medication(s) and type of reaction

Are you allergic or sensitive to other materials? Yes No

If yes, list material(s) (latex, iodine, etc) and type of reaction

Do you wear dentures or have a removable bridge? Yes No

When did you last eat?

When did you last drink?

Additional information you would like to give to your doctor about this procedure:

***PLEASE ALSO FILL OUT THE MEDICATION FORM PRIOR TO YOUR FIRST VISIT***

If you recieve sedation, you may not operate a motor vehicle, mechanical/electrical equipment, or make any critical decisions until the next day after your procedure. Doing any such activities could lead to injury to yourself and/or others.

Patient/Authorized representative signature (full name)